Module 8 Practice Quizzes

apply the dressing with a binder.

A client has developed blisters around the tape that secures the dressing. What nursing action would be appropriate to prevent further damage to the tissues?

identifying systemic factors on the unit that may have contributed to the event

A near miss has taken place on a medical unit in which a client nearly received a unit of packed red blood cells of an incompatible blood type. In the follow up to this event, which action should be prioritized?

65-year-old incontinent client with a hip fracture on bed rest

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer?

dehiscence.

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for:

near the client's hip, with legs shoulder-width apart and one foot near the head of the bed

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed?

a transparent film

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

mass trauma terrorism.

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of:

The client is aware of spatial relationships to avoid the table.

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?

Move the client to edge of the bed opposite the side that client will be turning.

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?

figure-of-eight turn

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

thrombus formation

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize?

Hair dryer is placed next to the sink.

The nurse is providing safety teaching to the family of an older adult client. Which finding in the client's home will the nurse teach the family to address?

Suggest to the nurse manager that an in-service on abbreviation use would be helpful.

The nurse is reading another nurse's notes that were recorded in the electronic health record (EHR) during the previous shift. What is the appropriate nursing action when numerous unapproved abbreviations are noticed in the previous nurse's notes?

"Picture yourself with good posture standing; that is how good lying posture works."

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include?

"Very little scar tissue will form."

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include?

Wash hands thoroughly after removing gloves with a pH balanced soap.

The nurse is teaching a nursing student about proper latex glove use. Which teaching will the nurse include?

Ask to examine the client alone in order to speak to her privately.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

decreased heart rate

What is a benefit of regular exercise over time?

1. Use whirlpool treatments, if prescribed, until the ulcer is considered clean. 2. Keep the injury tissue moist and the surrounding skin dry. 3. Use a dressing that absorbs exudate but maintains a moist healing environment.

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure injury? Select all that apply.

is demonstrating a common gait for the older adult.

The nurse observes an older adult client walks walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating?

an 84-year-old male with four recent driving violations

The nurse recognizes that assessment for sensory-perceptual alterations is a priority for which client?

National Institute for Occupational Safety and Health (NIOSH)

The nurse recognizes that which organization requires that employers comply with ergonomic recommendations?

Trying to balance too many activities can result in sleep deprivation.

A 14-year-old boy is in the clinic for his well-child exam. When the client asks his mother if she has any questions for the practitioner, she states "He sleeps so much. I am worried about how lazy he is." What does the nurse know to be true about sleep in adolescents?

"Be sure to drink 8 ounces of water when you take alendronate, and take it on an empty stomach."

A 59-year old female client reports to the nurse that she recently began taking alendronate and has been having stomach cramping, nausea, and diarrhea. How will the nurse educate the client?

placing a small towel under the neck

A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate?

True

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

Dilute with water or milk

A caregiver of a toddler has called the poison control nurse to report that the child licked a small amount of petroleum jelly. The caregiver states that the toddler is sitting on the floor, watching a cartoon, and playing with a toy. Which information will the poison control nurse provide?

1. Drowsiness 2. Headache 3. Vomiting

A child is playing soccer and is involved in a head-to-head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? Select all that apply.

hydraulic lift.

A client is discharged to his daughter's home. He weighs 250 lb (113.4 kg) and is immobile. The nurse should instruct the daughter on the use of a:

Client is in supine position with arms in functional position and pillow support under the knees.

A client is lying on her back with her arms at her side and knees supported with a pillow. What nursing documentation is most appropriate for this client?

Apply sterile dressings with normal saline over the protruding organs and tissue.

A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention?

"It is important to keep your sutured incision clean."

A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include?

Fowler's

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client?

The hospital must bear any costs incurred for treating the client's injury.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on his coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation?

If an ambulating client whom a nurse is assisting begins to fall, the nurse should slide the client down his own body to the floor, carefully protecting the client's head.

A client will be ambulating for the first time since his cardiac surgery. What should the nurse consider when assisting this client?

"I hold the boxes away from my body so I don't drop them on my feet."

A client works in a warehouse and has been having low back pain. Which statement would indicate the need for more education regarding safe lifting?

Stage II

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

footdrop.

A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from:

primary intention.

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

The nurse includes the client as a member of the health care team.

A nurse follows the universal client compact principles for partnership when providing care for clients. Which nursing action reflects this philosophy?

Consult with a colleague and identify the source of the error signal before proceeding.

A nurse is administering a scheduled medication to a client using the institution's bar code system. The nurse has scanned the client's armband as well as the scheduled medication. The system has signaled a discrepancy between the dose ordered and the dose scanned. What is the nurse's most appropriate response?

Serosanguineous

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow, thin, and contains plasma and red cells. What describes this type of drainage?

Use pillows to maintain a side-lying position as needed.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

Transparent

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

Clean the wound from the top to the bottom and from the center to outside.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

The nurse should question the client about the source of the bruises.

A nurse is completing an intake assessment. The nurse notes that an older adult male client appears to have bruises in varying stages of healing. Which action by the nurse indicates an understanding of her responsibilities?

Serosanguineous

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document?

Depth

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report?

Position a friction-reducing sheet under the client to facilitate movement.

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse?

Swimming

A nurse is recommending aerobic exercise for a client who is overweight. Which exercise might the nurse suggest?

"Parents are effective role models for children when they also wear helmets while riding."

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

1. Use filtering software to block objectionable information. 2. Investigate any public chat rooms used by the children. 3. Be alert for downloaded files with suffixes that indicate images or pictures.

A nurse is teaching parents about Internet safety for children. Which actions are recommended guidelines for Internet use? Select all that apply.

1. D—A nurse assesses drug and alcohol use of the patients. 2. A—A nurse assesses the age-related physiologic status of the patients. 3. M—A nurse reviews patient charts for medical problems affecting falls.

A nurse is using the DAME acronym to perform fall assessments on older adults in a home health care setting. Which examples of nursing actions follow this guideline? (Select all that apply.)

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Pull the fire alarm lever.

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which action should the nurse take?

Assessment of vital signs and respiratory status

A school-age child is admitted to the emergency room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was "knocked out" for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the client?

impetigo.

A skin infection caused by beta-hemolytic streptococci common in children is:

"To prevent the legs from rotating outward."

A student nurse asks the nurse what trochanter rolls are used for when providing client care. What is the appropriate nursing response?

Activate the fire alarm and notify the appropriate person.

An acronym RACE is commonly taught as a means for remembering priorities for action during a fire. The "A" in this acronym stands for which of the following?

carpal tunnel syndrome.

An administrative assistant at a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has:

"Your wound will heal slowly as granulation tissue forms and fills the wound."

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

can occur when repositioning uncooperative clients.

The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when she states that back injuries:

Place all household cleaners out of reach.

The nurse is teaching the caregiver of a 3-year old about safety. Which teaching will the nurse include?

"Do not douche 24-48 hours before the procedure."

The client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment?

19-year-old male college student majoring in physics

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use?

Gloves must be changed every 30 minutes to maintain barrier protection.

The facility where the nurse works has changed from latex gloves to vinyl, powder-free gloves to protect clients with latex allergies. Which education will the nurse provide to the unlicensed assistive personnel (UAP) about this new type of glove?

a client sitting in a chair who slides down

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

polypharmacy and use of multiple extension cords.

The nurse educator has just completed a lecture regarding older adults and hazards in the home. The nurse educator recognizes that the education was effective when the students state that common dangers in the home setting of an older adult include:

steps into the walker when walking.

The nurse has been educating the client about how to use a walker safely. The nurse knows the education has been effective when the client:

gauze

The nurse has collected blood from a client for laboratory analysis. Which dressing supply will the nurse select to cover the site from which the blood was drawn?

Apply an allergy-alert identification bracelet on the client.

The nurse has just admitted a client with a latex allergy to the medical-surgical nursing floor. Which is the priority nursing intervention?

trapeze bar

The nurse is working to increase functional ability with a client. Which assistive technique should be included in the plan of care?

Replace common healthcare items with latex-free equipment.

The nurse is admitting a client to a medical-surgical unit who states, "If someone brings balloons to me, I might have trouble breathing." What is the appropriate nursing action?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

predisposition to renal calculi

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

the client flexes the knees for support.

The nurse is assessing an older adult client and observe the client attempting To compensate for the shift in the center of gravity, What assessment does the nurse document?

the 24-month-old child who is unable to walk unassisted

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

transfer belt

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring?

The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors.

The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day?

Hemostasis phase

The nurse is caring for a client in the emergency department with a cut receivied 15 minutes ago while preparing dinner at home. The nurse understands the client's wound is in which phase of wound healing?

Keep the swab and the inside of the culture tube sterile.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

1. Communicate with family regarding need for restraints. 2. Check circulation and skin condition frequently and regularly. 3. Offer opportunities for toileting frequently and regularly.

The nurse is caring for a client who has been placed in physical restraints. Which nursing action is appropriate? (Select all that apply.)

Pull the shoulder blade forward and out from under the client.

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which action should the nurse take next to decrease the risk of impaired skin integrity?

Gauze

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?

Stage IV

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury?

"I will put a layer of cloth between my skin and the ice pack."

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

Sims'

The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination?

Take the restraints off, stay with her, and talk gently to her.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client?

Fish

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

a critical care client

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury?

Return the arm to the starting position at the side of the body.

The nurse is performing range-of-motion exercises on a client's arm. The nurse starts by lifting the arm forward to above the head of the client. Which action would the nurse perform next?

shortness of breath after walking up five stairs

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern?

Refrain from using extension cords.

The nurse is providing discharge teaching to the family of an older adult client. Which teaching will the nurse include to decrease the risk for electric shock?

"Steri-Strips will hold my wound together until it heals."

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching?

"It provides a way to remove drainage and blood from the surgical wound."

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

A client who has leg strength and can cooperate with the movement

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

having two nurses independently check the dosage of high-risk medications.

The nurses on a critical care unit can utilize the safety strategy of redundancy by:

"You are free to move onto the stretcher without assistance, but I will supervise for your safety."

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response?

Acts to prevent injury to the client and/or nurse

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which reason?

supine

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep?

"Is your child breathing at this time?"

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response?

gas stove

The residential home nurse is caring for a client who lives in an assisted living unit. In designing a plan of care to prevent fires, the nurse identifies which as the highest risk to the client?

Use protective sporting equipment.

The school nurse is educating 7th grade children about safety. Which recommendation is most appropriate for this age group?

puncture

The spouse of a client limps into the emergency department and states, "I stepped on a nail and didn't have shoes on. Now I can barely walk." What type of injury does the nurse anticipate?

Desiccation

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

"Do you experience incontinence?"

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

Shift their weight back and forth, from back leg to front leg.

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

If the client is in pain, administer analgesics in advance of the transfer.

Two nurses will transfer an older adult client from her bed to a chair later in the day. How can the nurses best facilitate a successful transfer?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

Using proper body mechanics, which motions would the nurse make to move an object?

Multiple roles, including triage and the distribution of resources

What best describes the nurse's role in disaster preparedness?

Providing prompt recognition of the potential or actual threat to safety

What is the primary role of the nurse in the care of clients who experience domestic violence?

the middle-age computer programmer

When assessing the physical activity of clients, the nurse would be most concerned about which client?

shearing force

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

have a meeting place outside the home.

When educating families on fire safety, it is important to:

maintain the natural alignment of the client's body.

When logrolling a client, the nurse should use supportive devices in turning the client in order to:

have the client fold the arms across the chest.

When moving a client up in bed with the assistance of another caregiver, the nurse should:

Support the client from sliding in bed.

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure injury?

epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization

Which best describes the third phase of the wound healing process: proliferative?

Nurse practitioner

Which level of health care provider may make the decision to apply physical restraints to a client?

1. Adjust the bed to the flat position or as low as the client can tolerate. 2. Begin ROM exercises at the client's head and move down one side of the body at a time. 3. Move each joint in a smooth, rhythmic manner.

Which nursing actions would the nurse perform when assisting clients with passive ROM exercises? Select all that apply

Social pressure

Which reason best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

"We place our baby in a rear-facing car seat in the back seat of the car."

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for a 9-month-old infant?

"Most people who die in home fires die from inhalation and not from burns."

Which statement should the nurse include in the teaching plan for a family learning about fire safety?

a cane with four prongs on the end (quad cane)

Which type of mobility aid would be most appropriate for a client who has poor balance?